deformity, and marionette lines were evident. The nasolabial fold was relatively mild. The neck showed no significant aging deformity. In the presurgical planning, the preauricular skin was pulled with fingers, which showed the improvement of depression in the lower cheek and jowl. The patient requested for the lift of the lateral canthal area. The simulation of facelift and temporal lift showed significant pulled appearance of lateral canthal area in the superolateral direction and also the tightening of the lower eyelid and correction of its protrusion. After comparing with two types of simulation, the patient chose to have the temporal lift and facelift. It was anticipated that lift procedure would correct the cheek hollow without filling. The lipofilling was planned in upper midface, marionette line, nasolabial fold, and lips.

The incision was made along the temporal hairline and in the preauricular area. After the subcutaneous dissection from the temporal incision, the lateral quadrant of orbicularis oculi muscle was excised. The suborbicularis dissection and muscle suspension at the lateral corner was performed for tightening of the lower eyelid with no removal of the orbital fat. The subSMAS dissection released the lateral row of the zygomatic ligaments and all the masseteric ligaments. The lipofilling was carried out after suspension of SMAS and zygomatic ligaments and skin closure. The subcision was used in the nasolabial folds and marionette lines prior to fat injection. In the temporal region, excess skin was trimmed and closed under minimal tension just enough to eliminate possible dents resulting from orbicularis muscle suspension at the lateral canthal area. No deep dissection or deep suspension was used in the temporal area.

One year after surgery, the patient showed correction of hollow cheek and jowl deformity. Although the nasolabial fold had improved, the marionette line showed little improvement. The lower eyelid revealed tightening and reduction of bulge.

References

1.Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83:11–6.

2.Mendelson BC, Muzaffar AR, Adams Jr WP. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002;110:885–96.

3.Muzaffar AR, Mendelson BC, Adams Jr WP. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg. 2002;110:873–84.

4.Mentz III HA, Ruiz-Razura A, Patronella CK, Newall G. Facelift: measurement of superficial muscular aponeurotic system advancement with and without zygomaticus major muscle release. Aesthetic Plast Surg. 2005;29:353–62.

5.Mendelson BC. Surgery of the superficial musculoaponeurotic system: principles of release, vectors, and fixation. Plast Reconstr Surg. 2001;107:1545–52.

6.Hamra ST. A study of the long-term effect of malar fat repositioning in face lift surgery: short-term success but long-term failure. Plast Reconstr Surg. 2002;110:940–51.

7.Barton Jr FE, Hunt J. The high-superficial musculoaponeurotic system technique in facial rejuvenation: an update. Plast Reconstr Surg. 2003;112:1910–17.

8.Ozdemir R, Kilinc H, Unlu RE, Uysal AC, Sensoz O, Baran CN. Anatomicohistologic study of the retaining ligaments of the face and use in face lift: retaining ligament correction and SMAS plication. Plast Reconstr Surg. 2002;110:v 1134–47.

31.1 Introduction

The author refers to a facelift as facial rejuvenation since the word facelift is confusing to both the patient and surgeon. It is also a misnomer, and dividing the face could be difficult as some muscles, like platysma, have a wide origin.

In today’s modern surgery, one tends to combine one surgical procedure and one nonsurgical procedure at the same time so it is more appropriate to refer to the whole procedure as rejuvenation.

31.2 Consultation

This is a vital part of the operation. The patient must see you personally, not counselors or representatives, as they might increase the expectations to unrealistic levels which might come back to “bite” you. Always have a chaperone with you who you might need as a witness in the future. She or he will also be a silent evaluator of the patient. Normally, the author has a nurse and my fellow, who are usually familiar with the methods. The Consultation Form is used (Table 31.1).

At consultation, the patient must be asked “what is it that brings you here?” It is preferable to ask her this question with a mirror in her hand, and listen intently before examining her. The consultation goes

A. Erian

Pear Tree Cottage, Cambridge Road,

Wimpole 43, SG8 5QD Cambridge, United Kingdom e-mail: plasticsurgeon@anthonyerian.com

in chronological order, so you methodically focus on her face and exclude any problem that might interfere with the surgical management. It is essential to document all the areas that you can fix/improve by surgery, and others that might not achieve a good result.

The elements of the face are examined:

1.Skin being the largest organ in the body, it deserves special attention and also influences the outcome. Getting the skin in its best possible form is very important.

2.The bone structure. It is important to assess the skeletal deformities that can influence the result, especially the chin, as a receding chin might need some form of augmentation as it seems to affect the result especially, from the profile, and the opposite is true.

31.3Counseling, Imaging

and Preoperative Preparation

After an initial consultation, the patient is invited again for a further consultation with the team and a psychologist to ascertain the mental state and frame of mind that can be missed in the initial consultation. This seems to lower litigation and prepare the patient more fully.

In the same visit, imaging is sometimes done, especially in profile surgery, rhinoplasty, or chin or cheek implants, after the patient signs a form that they understood is only image simulation.

The lab work necessary for the procedure is done and any special tests the anesthetist may wish to be done.

The patient is given the consent form and the preand postoperative instructions at this stage (Table 31.2).